Request For Further Action By Legal Counsel {RFA-1LC}

SEE IMPORTANT INFORMATION ON REVERSERFA-1LC (4-17)INSTRUCTIONS: The claimant seeks Board action regarding the claim identified above for the following reasons (check all that apply). Please note that the required documentation identified below must be attached to the form and submitted to the Board or must be referenced in the space provided below** (by date, name or title of document, and form ID) if it is already in the Board's electronic file. This form must be mailed, faxed or emailed to the Workers' Compensation Board. (See mailing and email filing address on reverse side).STATE OF NEW YORK - WORKERS' COMPENSATION BOARD REQUEST FOR FURTHER ACTION BY LEGAL COUNSEL 8.(documentation of medical disability and current earnings required) d. Payments should be adjusted as claimant is working at reduced earnings as of CERTIFIED BY (Please Print Name) DATE PREPARED (MM/DD/YY) ATTY/REP ID NO. AREA CODETELEPHONE NUMBER RCompensation:Other:Medical Issues: 2. CLAIM ADMINISTRATOR CLAIM (Carrier Case) NO. ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERSThis form is for use by claimant's attorney or licensed representative ONLY. Unrepresented claimants should use Form RFA-1W or ask for Board assistance. 1. WCB CASE NO.ADDRESS TO WHICH NOTICES SHOULD BE SENT NAME 4. CLAIMANT 5. EMPLOYER (at time of injury) 6. INSURER 7. ATTORNEY / LICENSED REP. APT. NO. Check if new address: 3. DATE OF INJURY (MM/DD/YY) on (date) and that:I certify that this request for Board action is based upon reasonable grounds, has been submitted with my client's consent, and that this form with attachment(s) has been provided to the opposing party(ies). I also certify that (check one box below): on (date) to discuss the issue(s) above, that I have waited a reasonable time for a response, but that no discussion was forthcoming. b. Payments have been suspended or reduced on g. Payments have not been paid as directed by Decision filed on (documents required) **Document reference information (date, name/title,form ID): e. Payments should be adjusted as claimant has concurrent employment. f. Payments should be resumed as claimant has been released from incarceration on h. Claimant's medical condition has changed. (medical documentation indicating change required) i. Claimant's request for medical treatment has been denied or has not been addressed. j. Claimant's disability is now permanent. (medical Form C-4.3, Doctor's Report of MMI/Permanent Impairment required) k. Claimant's request for medical and transportation reimbursement has been denied or not addressed. (receipts and Form C-257 required) Check this box if the claimant was under 25 years of age at time of accident. Check this box if the claimant accepts the insurer's opinion on the severity of disability/loss of use. l. Parties have reached an agreement (Form C-300.5 or written stipulation, Form C-312.5 or proposed findings or Form C-32 required) m. Claimant has discontinued or settled a lawsuit pertaining to the accident/injury of this claim. n. Claimant has new or requested documentation regarding o. Other (explain fully in the space provided below.) no settlement of the issue(s) could be reached. settlement of the issue(s) was reached (documentation required ). I have discussed the issue(s) above with the opposing party(ies) or its representative(s) (give name of person contacted ) I have attempted to contact (name) An attorney/licensed representative fee is requested and Form OC-400.1 has been submitted. c. Payments should be suspended as claimant returned to work at full wages on (documentation of weekly gross pay preceding injury and statement from second employer regarding lost time required) a. Payments should begin as claimant is not working as of (medical documentation indicating disability required) and now seeks benefits.(medical documentation indicating disability and release from custody documentation required)(documentation indicating denial of request for medical treatment required. Please use Form MG-2 for variance denials.)(documents indicating discontinuance, settlement, or closing statement required)An expedited (45-day) hearing is requested under WCL 25(2)(a). By checking this box I affirm that: A claim has been filed for a work related injury; the employer is not paying wages; the claim has not been denied; there has not been a decision barring the claimant from compensation. I have reached out to the insurer to try to resolve the issue and was unable to resolve it. I understand that I may be liable for a penalty if I check this box and any of the above conditions do not apply. American LegalNet, Inc. www.FormsWorkFlow.com Notification Pursuant to the New York Personal Privacy Protection Law (Public Officers Law Article 6-A) and the Federal Privacy Act of 1974 (5 U.S.C. 247 552a). The Workers' Compensation Board's (Board's) authority to request that claimants provide personal information, including their social security number, is derived from the Board's investigatory authority under Workers' Compensation Law (WCL) 247 20, and its administrative authority under WCL 247 142. This information is collected to assist the Board in investigating and administering claims in the most expedient manner possible and to help it maintain accurate claim records.240 Providing your social security number to the Board is voluntary. There is no penalty for failure to provide your social security number on this form; it will not result in a denial of your claim or a reduction in benefits.240 The Board will protect the confidentiality of all personal information in its possession, disclosing it only in furtherance of its official duties and in accordance with applicable state and federal law.240 RFA-1LC (4-17) REVERSETo the Claimant's Representative - General Information On Using This FormYou may file this form with the Workers' Compensation Board when you want the Board to take a specific action in your client's case, or if you need to alert the Board to any problem or situation that is affecting your client's case. Many of the most frequently requested actions/situations are contained in Section 8.However, you are not limited to those listed. Check all that apply and/or add additional information or explanation in the space provided (o). If an attorney/licensed representative fee is requested, submit Form OC-400.1. Please note: in order to receive an expedited (45-day hearing) you must check box 'a' and enter the date the claimant stopped working, AND you must check the box below for240223An expedited (45-day) hearing is requested under WCL 25(2)(a)224. Complete the identifying information at the top of Form RFA-1LC and send the form, WITH ALL APPLICABLE EVIDENCE ATTACHED, to the Workers' Compensation Board (see address below). The Board will contact you and all parties when it takes action on your client's case. YOU MUST CERTIFY THAT YOU HAVE DISCUSSED THE ISSUE(S) OR ATTEMPTED TO CONTACT THE INSURER/EMPLOYER AND HAVE BEEN UNABLE TO SETTLE THE OUTSTANDING ISSUE(S). YOU MUST SEND A COPY OF THIS FORM TO YOUR CLIENT, THE INSURER(S), OR DIRECTLY TO THE EMPLOYER OR ITS THIRD PARTY ADMINISTRATOR IF THE EMPLOYER IS SELF-INSURED. Additional information about the Board, including information about Board forms, is available at the Board's web site: www.wcb.ny.gov. If you would like on-line access to your client's case, you can register for eCase using the registration instructions available on the Board website under the eCase link. ADDITIONAL INFORMATIONUpon the submission of this form with the applicable documentary evidence, the Board will take immediate action to advance your client's claim toward resolution. Some of these actions include, but are not limited to the following:- Proposing an Administrative Determination An Administrative Determination (AD) is a decision concerning your client's claim rendered by the Board. All the evidence in your client's file is examined prior to an AD being issued. Once an AD is sent to the parties, any party may object to the determination within 30 days. If there is no objection, the determination becomes final. Appearance at the Board is not necessary because acceptance of an AD indi